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NATIONAL ROAD MAP
August 2010
August 2010
National Road Map
TABLE OF CONTENTS
Table of Contents ............................................................................... (i)
Foreword ........................................................................................... (ii)
Acknowledgements ............................................................................ (iii)
List of Abbreviations ........................................................................... (iv)
Executive Summary ............................................................................ (v)
Introduction ....................................................................................... 1
The Current Situation of MNH ............................................................. 2
The Kenya Maternal and Newborn Health Model ................................... 8
Challenges in the Implementation of MNH Services ............................... 9
Guiding Principles of the Road Map ...................................................... 11
The Road to Safe Motherhood ............................................................. 12
The Kenya MNH Road Map .................................................................. 13
Objectives, Strategies and Appropriate Interventions ............................ 13
Monitoring and Evaluation of Maternal and Newborn Health .................. 15
Roles and Responsibilities ................................................................... 17
Implementation Framework ................................................................ 19
References ......................................................................................... 23
Annex 1: Millennium Development Goals and Targets ............................ 25
Annex II: Minimum Package of MNH Services by KEPH Level ................. 27
Annex III: Policy Guidelines, Frameworks and Standards Developed to Guide
the Implementation of SRH Programmes in Kenya ............................... 28
Annex 1V: Costing of the MNH Road Map ............................................ 30
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FOREWORD The high level of Maternal and Newborn morbidity and mortality has not changed substantially over the last decade as shown by the WHO 2007 report, with many women in Africa dying each year from compli-cations of pregnancy and childbirth. The disability and death of a mother hinders child survival, destroys families, takes children out of school and lowers household and community economic productivity, thus posing a serious challenge to the broader social economic development. Improving Maternal Health (MDG 5) is often called the ‘heart of MDGs’ because if it fails, the other MDGs will also fail. Addressing Safe Motherhood is human rights imperative. It is estimated that 7,700 Kenyan women die each year because of pregnancy-related causes. This translates to approximately 21 women each day or almost one Kenyan woman every hour. Further the Kenya Demographic Health Survey (2008/09) indi-cates that maternal mortality levels in Kenya have remained unacceptably high at 488 per 100,000 live births, with some regions reporting MMRs of over 1000 /100 000 live births. Notably, MDG 5 (Reduce maternal death to 147 per 100,000 by 2015) is doing poorly and there is need to redouble our efforts towards attaining this goal. In addition, around 1.12 million newborns die before they complete their first month of life and another one million babies are stillborn every year. Neonatal mortality rate in Kenya is estimated at 31 deaths per 1,000 live births (KDHS, 2008/09), a very marginal reduction when compared to the other child health indicators that have shown significant improvement. Vision 2030 aims to provide equitable and affordable health care of the highest affordable standard to all citizens, by restructuring health care delivery systems with a shift of emphasis to preventive and promo-tive health care. The emphasis is on access, equity, quality, capacity and institutional framework. The Health Ministries’ core function is to support the attainment of the health goals of the people of Kenya by implementing priority interventions in health, based on their mandate and guided by the Strategic Framework for National Transformation 2008–2012 and the wider health sector. In pursuant of this, the Ministries of Health support the implementation of Vision 2030 and MTP 2008–2012, along with the broad goals of the National Health Sector Strategic Plans. The National Maternal and Newborn Health (MNH) Road Map is adapted from the Africa Regional Road map following an agreement by all AU countries to accelerate the attainment of MDGs 4 and 5. The Implementation framework of the strategies adopted for the Road Map require concerted efforts by all stakeholders in the Health Sector from national level down to the community and across the political, social, and corporate divide.
It is envisioned that the implementation of this MNH Road Map will accelerate the attainment of MDG 5, thereby ensuring a vibrant and healthy Kenya. Let us all pull together in the national spirit of ‘Harambee’ and make this a reality.
Mark K. Bor, CBS Mary NgarePermanent Secretary Permanent SecretaryMinistry of Public Health and Sanitation Ministry of Medical Services
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ACKNOWLEDGEMENTS
The development of the National Road Map involved extensive consultation with key stakeholders in maternal and newborn health. The Ministry of Public Health and Sanitation would like to thank the Director of Public Health & Sanitation, Dr. S. K. Sharif and the Head of Department of Family Health Dr. Josephine Kibaru for providing policy guidance in the development of the National Road Map.
The commitment, technical support and overall stewardship of the task force from the following institutions are highly appreciated: Division of Reproductive Health (DRH-MOPHS), World Health Organization (WHO), United Nations Population Fund (UNFPA), Essential Health Services (EHS), UON Department of Community Health, Division of Obstetrics & Gynaecology - Ministry of Medical Services (MOMs) and Population Council who formed the core team of the task force.
The following are specifically mentioned for their continued input to the Road Map over various periods of time - Dr. Janet Wasiche (then Head DRH), Dr. Shiphrah Kuria, Annie Gituto, Elizabeth Washika, Selina Cherutich, Ruth Muia, Mary Gathitu and Diane Kamar (DRH); Dr. Gathari Ndirangu (DRH/Capacity); Paul Dielemans (EHS); Dr. Simon Mueke (MOMS); Dr. Nancy Kidula and Dr. Joyce Lavussa (WHO); Prof. Joyce Olenja (UON/Community Health); Charlotte Warren and Annie Mwangi (Population Council); Dr. Stephen Wanyee (UNFPA) and Dr. Kennedy Ogwae (UNICEF).
We cannot forget the contribution of individuals of the various Divisions, Departments, Provincial and District Reproductive Health teams, FBOs, NGOs and Private Organizations who also gave valuable inputs during the consensus building meeting. They include:
• Division of Health Promotion • Division of Vaccines & Immunization • Division of Nursing-MOMs• Nursing Council of Kenya • Health Information System • Division of Nutrition • The Midwives Chapter • Nairobi Province-MOPHS • Eastern Province-MOPHS/MOMs• Western province MOPHS/MOMS • Nyanza Province-MOPHS/MOMs• Catholic Secretariat • Family Health Options • HSLP
Finally we appreciate the support given by the Head of Division of Reproductive Health, Dr. Bashir Issack, as we finalized the Document.
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LIST OF ABBREVIATIONS
ANC Antenatal Care ASRH&DP Adolescent Sexual Reproductive Health and Development
Policy BBI Better Births Initiative D&C Dilation and Curettage FCI Family Care International FP Family Planning HIV Human Immunodeficiency Virus ICPD International Conference for Population and Development IEC Information Education Communication KAIS Kenya AIDS Indicator Survey KDHS Kenya Demographic Health Survey KSPA Kenya Service Provision Assessment Survey LBW Low Birth Weight MDG Millennium Development Goals MMR Maternal Mortality Rate MNH Maternal and Newborn Health MOH Ministry of Health MTCT Mother –to –Child Transmission NASCOP National AIDS and STI Control Program NHSSP National Health Sector Strategic Plan OBA Output-Based Aid PEPFAR US President’s Emergency Plan for Aids Relief PMTCT Prevention of Mother to Child Transmission PRHT Provincial Reproductive Health Team DRHT District Reproductive Health Team RH Reproductive Health RHICC Reproductive Health Inter-agency Coordinating Committee SWAPs Sector Wide Approaches UN United Nations UNDP United Nations Development ProgrammeUNFPA United Nations Population FundWHO World Health Organization
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EXECUTIVE SUMMARY
Maternal and neonatal morbidity and mortality continue to be recognised internationally as public health priorities. More than 15 years since the launch of the Safe Motherhood Initiative (SMI), maternal and neonatal mortality levels in Africa have sadly continued to rise instead of decline. Of all maternal deaths occurring globally, 99 percent of them occur in developing countries with Sub-Saharan Africa having the highest maternal mortality ratio (MMR) of 900,000 maternal deaths per 100,000 live births and also the highest lifetime risk of maternal deaths of 1:26. Consequently, now more than ever before, the international community realises that unless greater investments are made, MDG 5 will not be attained in Africa.
Maternal mortality levels in Kenya have remained unacceptably high at 488 maternal deaths per 100,000 live births, (with some regions reporting MMRs of over 1000 /100 000 live births). Neonatal mortality rate is estimated at 31 deaths per 1,000 live births (KDHS, 2008/09) from 33 deaths per 1,000 live births (KDHS, 2003), a very marginal reduction when compared to the other child indicators that have shown significant improvement. Currently NMR is contributing 67% of IMR. This implies that reduction in newborn mortality would put Kenya on track for attainment of MDG 4.
The slow progress in attainment of Maternal and Newborn health targets in Kenya can be attributed to: i) Limited availability, poor accessibility and low utilization of skilled birth attendance during pregnancy, child birth and postnatal period, ii) low Basic Emergency Obstetric and Newborn Care coverage iii) Poor involvement of communities in maternal and newborn care iv) Limited national commitment of resources for maternal and newborn health. The key strategies proposed to accelerate the attainment of MDG 4&5 include: improving availability of, access to, and utilisation of quality maternal and newborn health care; reducing unmet need through expanding access to good quality family planning options for men, women and sexually active adolescents; strengthening the referral system; advocating for increased commitment and resources for MNH and FP services; strengthening community based maternal and newborn health care approaches; and strengthening the monitoring and evaluation system and operations research.
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The goal of the National MNH Road Map is to accelerate the reduction of maternal and newborn morbidity and mortality towards the achievement of the Millennium Development Goals (MDGs). The specific objectives are:
i. to increase the availability, accessibility, acceptability and utilisation of skilled attendance during pregnancy, childbirth and the post partum period at all levels of the health care delivery system;
ii. to strengthen the capacity of individuals, families, communities, and social networks to improve maternal and newborn health, and lastly.
iii. to strengthen data management and utilisation for improved MNH.
The National MNH Road Map offers a new and revitalised dimension of efforts of all stakeholders. It provides a framework for building strategic partnerships for increased investment in maternal and newborn health at both institutional and programme levels. Implementation will take a phased approach and the final reporting year will be 2015.
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INTRODUCTION
Maternal and newborn morbidity and mortality continue to be recognised internationally as public health priorities. The Global Safe Motherhood Initiative launched in Nairobi in 1987 aimed at reducing the burden of maternal deaths and ill health in developing countries. The 1994 ICPD Program of Action later called for a paradigm shift in strategies and policies in the provision of comprehensive and quality reproductive health services. These led to the Millennium Declaration in 2000 and development of goals with indicators.
A major contribution towards the achievement of the MDGs is the commitment of governments of developing countries and the international community, who have adopted the MDGs as their framework for development and cooperation. Two key MDGs relevant to maternal and newborn health are: MDG 4 – reduction in child mortality and MDG 5 - improved maternal health. These goals provide targets for countries in their efforts towards reducing maternal mortality, and increasing both skilled attendance and contraceptive prevalence rate. Other relevant MDGs include No. 3 - Gender equity and women’s empowerment and No. 6 – Combat HIV/AIDS, malaria and other diseases.
The UN recognises that MDGs cannot be achieved in low resource settings without attention to population issues and access to sexual and reproductive health information and services (UNDP, 2005). In order for the achievement of MDG 5 to be made a reality, MMR will have to decrease at a much faster rate, especially in Sub-Saharan Africa where the annual decline has so far been about 0.1 percent compared to the expected decline rate of 5.5 percent. The realization of this goal will require increased attention to improved health care for women, including: improved access to health services, reduced unmet need for family planning services, prevention of unsafe abortions, provision of high quality pregnancy and delivery care including essential obstetric care (WHO, 2007). Quick win interventions are therefore being recommended, among them expanding access to SRH information and services, including family planning, and closing the existing funding gap for supplies and logistics (UNDP, 2005). Efficient and effective skilled care during and after labour and delivery can make the difference between life and death for both women and their newborns, as complications are largely unpredictable and may rapidly become life threatening (WHO, 2005).
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THE CURRENT SITUATION OF MNH Maternal Health Maternal and newborn conditions account for a substantial part of the health gap between the developed and developing countries. Of the estimated 536,000 maternal deaths that occurred in 2005 globally, 99 percent (533,000) occurred in developing countries with Sub-Saharan Africa having the highest MMR at 900 maternal deaths per 100,000 live births. The adult lifetime risk of maternal deaths is highest in Africa (1:26), followed by Oceania (1:62), and Asia (1:62); compared with developed countries, where the risk is 1: 7300 (WHO, 2007). Major causes of maternal mortality in SSA are depicted below.
Figure 1: Causes of Maternal Mortality in the African Region
Source: UNDP, WHO, UNFPA, World Bank (2006). Causes of maternal death.A systematic review. The Lancet 2006;367:1066-74
Approximately 13 percent of all maternal deaths occur among adolescents mainly as a result of complications of unsafe abortions (WHO 2008).
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3These are members of the society who are at risk with respect to maternal and neonatal health and they include; persons with disabilities,youth and adolescents, the poor in urban, rural and hard to reach areas, people infected or affected by HIV/AIDS, Or-phans and vurnerablechildren-homeless, refugees and abused persons (RH Policy, 2007)
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The most common causes of maternal morbidity and mortality (MOH-Kenya Annual Statistical Report, 2008) are: obstructed labour (29.5%), post partum haemorrhage (25%), ante partum hemorrhage (16.9%) and pre-eclampsia (16.9%).
The situation in Kenya with regards to MNH remains grim with the recently released KDHS 2008/9 basically showing very marginal improvements in the Maternal and Newborn care indicators. The Maternal Mortality Ratio (MMR) remains high at 488/100,000 (KDHS 2008/09). The proportion of mothers attending antenatal clinic at least once increased from 88% to 91.5%, deliveries by skilled attendants increased slightly from 40 to 42% and institutional deliveries increased slightly from 40.1 to 43.6% (KDHS, 2008/09). This means that over 50% of deliveries among Kenyan women are attended by unskilled persons; hence both mother and newborns are in danger should any complication arise during delivery or postnatal period. It is unlikely that the country will achieve the maternal mortality target of 147/100,000 by 2015 unless greater attention and efforts to increase skilled attendance are put in place.
Regional disparities within the country exist. Skilled birth attendance was found to be about 40% in Nyanza Province, 30% in North Eastern Province and 25% in Western Province. North Eastern Province has the highest MMR of 1,000-1,300/100,000 (KDHS, 2003). The urban poor also show very high levels of maternal mortality.
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1Kenya service Provision Assessment (KSPA) 2004.Safe motherhood Programmes: Options and issues. Deborah Maine Prevention of Maternal Mortality, Centre forPopulation and family Health
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Among women who deliver outside the health facility, a vast majority (8 out of 10) do not receive postnatal care. Only 10 percent attend postnatal care within two days of delivery, while 2 percent get care three to six days after delivery (KDHS, 2003). This is despite the fact that majority of maternal deaths occur during the postpartum period. Furthermore, nearly half (46%) of the population live below the poverty line and only 52% of Kenyans are within 5 kilometers of a functional health facility. Rural urban disparities in SBA are also prominent with urban areas showing skilled birth attendance of 72% (2003) and increasing to 75% (2008/09) while rural areas had SBA of 34% (2003) increasing to 37% (2008) (KDHS 2003; 2008/09). Equitable distribution of health facilities and services across the country is also lacking with urban areas having mainly CEOC while rural areas have mainly BEOC. The average recommended EOC facilities per 500 000 population remains low at 1.7 as compared to the recommended 5 EOC facilities/500 000 population.
Newborn HealthGlobal data from vital statistics indicates that in 2004 there were 133 million live births, 3.7 million of whom died in the neonatal period and 5.9 million during the perinatal period. Ninety-eight per cent of these deaths took place in the developing world, where 90% of babies were born (WHO, 2007). The top three causes of newborn death in Africa are infections (29%), prematurity (25%), and asphyxia (24%). Neonatal tetanus, which accounts for 6% of all new born deaths in Africa is one of the most cost-effective conditions to prevent.
Figure 2: Trends in Skilled Birth Attendance during Delivery
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The non improvement of maternal indicators is even more significant for neonatal survival. According to the KDHS 2008/09 neonatal mortality rate only reduced marginally from 33 to 31 per 1000 live births contributing to 42% of the under five mortality and 60% of infant mortality. This is an increase when compared to 29 percent of under five mortality and 42% of infant mortality in 2003 (KDHS). Achieving the MDG 4 targets in under-five mortality (33/1000) and infant mortality (26/1000) by 2015 will be a challenge unless neonatal care, which is closely linked to maternal care, receives more attention (Lawn and Kerber, 2006).
The most common causes of neonatal morbidity and mortality (MOH-Kenya Annual Statistical Report, 2008) are pre-maturity and low birth weight (30%), neonatal infections (27%) and birth asphyxia. Despite overwhelming evidence that exclusive breastfeeding for the first six months of life significantly enhances child survival (Jones, G; Steketee, R; Black, R; Bhutta, Z; & Morris, S. 2003), Kenyan reports indicate that only 35% of infants are exclusively breastfed up to the age of 6 months (KDHS, 2008/09).
Figure 3: Trends in neonatal, infant and under-five mortality in Kenya
MNH ServicesThe Kenya Service Provision Assessment (2004) indicates that only 33 percent of health facilities offer ANC, TT immunisation and post natal care. Normal delivery services are provided by 38 percent of facilities while only 7 percent provide caesarean section. Emergency transport is available in only 27 percent of the facilities (KSPA, 2004).
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Obstetric fistula is still a major problem in Kenya, and reflects on health systems failure in terms of early detection and management of complications of labour. The availability of post abortion care services are limited with only 16 percent and 14 percent of facilities offering delivery services having a manual vacuum aspirator and a D&C kit in place respectively (KSPA 2004). These findings demonstrate that Kenya still is far from attaining universal coverage of MNH care.
Results from the Kenya AIDS Indicator Survey 2007 show that the HIV prevalence rate among adults is 7.4% percent while that among pregnant women is higher at 9.0 percent. Although approximately 1.4 million people are currently living with HIV, the majority (83%) of HIV infected persons do not know their HIV status (KAIS, 2007).
Kenya’s target for PMTCT services as outlined in the KNASP II was to increase coverage of PMTCT services to reach 80% of pregnant women by end of 2008, and reduce paediatric HIV infections by 50%. This is in line with the UNGASS 2001 recommendations. The percentage of ANC attendees tested for HIV significantly increased from 50.4% in 2003 to 78.6% in 2007 (KAIS 2007). More work is being done to ensure universal HCT for all pregnant women in Kenya.
Family Planning in known to be a cost effective strategy to enhance maternal and newborn health, reduce maternal and newborn mortality and is one of the prongs of PMTCT. However in Kenya, contraceptive prevalence stands at 46 percent, family planning unmet need among married women aged 15-49 stands at 45.6 percent and the total fertility rate is 4.7. Family planning utilisation is poorest among adolescents with a CPR of 19.6% for any modern method. FP unmet need is very high among HIV positive women with 57.9% of these women not using any contraception at all (KAIS, 2007; KDHS, 2008/09). This may be attributed to the fact that the PMTCT programme is managed as part of the HIV /AIDS programme which gives low prioritisation to the FP prong.
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Reasons for Non Improvement of MNH Indicators in Kenya The main reasons for the non improvement of MNH include: low BOEC coverage, poor access to skilled attendance along the continuum of care, lack of community involvement in MNH, high unmet need for family planning and the delays in seeking appropriate skilled care.
The first delay entails a delay in decision making at household level hence the importance of community awareness and participation in MNH programmes. In Kenya, many of these deliveries take place in the villages as a result of ignorance - poor knowledge of danger signs, cultural issues, and poor status of women. Women are not empowered to make decisions on skilled birth attendance, and majority of men still control use of resources at household level.
The second delay involves a delay in moving the woman to hospital. Some women may be willing to go to health facilities, but are not able to go due to various barriers. These include: cost - the cost of maternal care services remains very high for most women in Kenya; access - health facilities are few and sparsely located; the poor state of Kenyan roads and unavailability of transport in many areas makes it hard for many women to access health services at time of need; and poor status of women - most women are not empowered to make decisions on health care due to low education and low socio-economic status.
In the third delay, there is delayed intervention at the facility. This normally arises as a result of poor infrastructure, lack of equipment, and lack of knowledge and skills in EmONC. Poor distribution of health workers has left rural facilities with few or no health workers to provide services. Unfriendly attitude by health workers has also been shown to lower utilization of maternal and newborn Health services.
MNH Policy and Strategy Environment • A National Reproductive Health Policy is in place. • A National Reproductive Health Strategy is in place • A Child Survival and Development Strategy (CSDS) has been developed. • A Health Policy & Financing Strategy is being finalised - the health care financing
strategy advocates for free health care for pregnant women and children under five years. Performance based financing has also been taken as an option in the draft financing strategy. Referral mechanism for community to be included as part of health care financing.
• Adolescent RH and Development Policy is in place.
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THE KENYA MATERNAL AND NEWBORN HEALTH MODEL
The six pillars of Maternal and Newborn Health in Kenya include: pre-conceptual care and family planning, focused antenatal care, essential obstetric care, essential newborn care, targeted post-partum care, and lastly post-abortion care. These services are underpinned by the foundation of skilled attendance and a supportive and functional health system. The Kenya MNH model recognises the potential role communities have in the promotion of their own health, the importance of strengthening the interface between the community and health services, as well as promoting the human rights approach to health service delivery. These are also identified by the NHSSP II 2005-2010 (currently extended to 2012) as key areas of focus.
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Figure 4: Kenya Maternal and Newborn Health Model
* M and E; health planning; financial & commodity supply management; functioning referral network; human resource management & development; quality assurance &standards; investment and maintenance; information, communication and technology; and perfomance monitoring
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CHALLENGES IN THE IMPLEMENTATION OF MNH SERVICES
Since the launch of the Safe Motherhood Initiative, efforts invested in maternal and newborn health programmes have not yielded the expected results due to several challenges. A combination of structural and infrastructural problems has had a negative effect on the successful implementation of MNH programmes.These include:
Challenges • Limited availability, poor accessibility and low utilization of skilled attendance
during pregnancy, child birth and postpartum period at all levels of the health care delivery system.
• Socio cultural barriers contribute to delay in seeking care as well as reluctance to adopt good practices through behaviour change, thereby increasing the risk of obstetric and newborn complications (for example mother’s preference to deliver at home with unskilled attendants), and lack of community based maternal and newborn care).
• Poor staffing and/or inappropriate staff deployment. • Inadequate health provider competencies in Essential Obstetric and Newborn
Care. • Inadequately articulation of MNH issues in pre-service training curricular. • Poor access to good quality MNH services including family planning. • Inadequate access by adolescents and youth to reproductive health information
and youth friendly services. • Low uptake of PMTCT services.• Inadequate integration of MNH and HIV/AIDS services. • Limited skills in planning and management for use in MNH programming. • Limited national commitment of resources for maternal and newborn health. • A weak public-private partnership in service delivery. • Limited participation of community, family and individuals in MNH.• Lack of gender perspective and male involvement.• Poor monitoring and evaluation. • Poor utilisation of research findings for evidence-based service delivery.
Opportunities • Enabling policies, guidelines, strategies and training materials in place. • Promising government and donor commitment. • Existence of coordination mechanism for MNH. • Promotion of the Better Births Initiative (BBI) and Baby Friendly Hospital
Initiatives (BFHI).
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• Adoption of appropriate approaches and best practices. • The National Community Strategy is being rolled out.• Men express readiness for involvement in MNH.• Gender mainstreaming efforts in MNH are underway. • Pre-service institutions showing interest in regular uptake and revision of
curricular.
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GUIDING PRINCIPLES OF THE ROAD MAP
The Kenya Road Map will be grounded on ten key principles. 1. Evidence–based: ensuring that the interventions are based on up-to–date
evidence.
2. Human rights approach, equity and accessibility: human rights and freedom must be respected and reflected through scaling up of cost-effective interventions that promote equitable access to quality maternal and newborn care services with special attention to the poor and vulnerable groups.
3. Health systems approach: focus on the delivery of maternal and newborn health at all levels, more so, using primary health care as an entry point for engaging community resources and strengthening the referral system.
4. Phased planning and implementation: promoting implementation in clear phases with timelines and benchmarks that enable re-planning for best results.
5. Complementarity: leveraging on existing programmes and recognising the comparative advantage of the different partners in the planning, implementation and evaluation of maternal and newborn health programmes.
6. Partnership: promoting partnership, coordination and joint programming among stakeholders including the private sector, professional associations and councils at all levels in order to improve collaboration, maximise resources and avoid duplication.
7. Clear definition of roles and responsibilities: defining the roles and responsibilities of all stakeholders in the planning, implementation, monitoring and evaluation of the maternal and newborn program is essential for increased synergy.
8. Promotion of gender equity and equality: promotion of gender equity and equality, including the elimination of all forms of gender-based violence and related harmful practices must be addressed at all levels of service delivery.
9. Male involvement: involvement of men as responsible partners to increase
access to and use of maternal and newborn health services.
10. Governance, transparency and accountability: promoting a sense of stewardship, accountability and transparency on the part of the government as well as other stakeholders for enhanced sustainability.
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THE KENYA MNH ROAD MAP - STRATEGIC DIRECTION
Vision: Efficient and high quality MNH services that are accessible, equitable, acceptable, and affordable for all Kenyans.
Goal: To accelerate the reduction of maternal and newborn morbidity and mortality towards the achievement of the Millennium Development Goals (MDGs)
Specific objectives 1. To strengthen data management and utilisation for improved MNH. 2. To increase the availability, accessibility, acceptability and utilisation of skilled
attendance during pregnancy, childbirth and the post partum period at all levels of the health care delivery system.
3. To strengthen the capacity of individuals, families, communities, and social networks to improve maternal and newborn health.
Objectives, Strategies and Appropriate Interventions Objective 1 Improve data management for decision making and utilisation in health planning
Strategy 1: Strengthen monitoring and evaluation system for Maternal and Newborn Health
Priority Actions / interventions1. Strengthen MNH data management and utilisation at all levels 2. Advocate for inclusion of MNH indicators in all the surveys and routine data
collection tools
Strategy 2: Strengthen operations research in Maternal and Newborn Health Priority Actions / interventions 1. Strengthen linkages between MNH stakeholders and research and training
institutions 2. Promote the documentation, dissemination and utilisation of evidence-based
practices
Objective 2 To increase the availability, accessibility, acceptability, and utilisation of skilled attendance during pregnancy, childbirth and the post partum period at all levels of the health care delivery system
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Strategy 3: Strengthening national, provincial and district capacity for health planning and management of MNH care. Priority Actions / interventions 1. Strengthen capacity of the national, provincial and district managers, in health
planning, management and facilitative supervision. 2. Strengthen joint programming between MNH and related programmes to
maximise resources. 3. Incorporate rights based approach and gender mainstreaming to advance MNH
within planning processes at all levels
Strategy 4: Improving availability of, access to, and utilisation of quality Maternal and Newborn Health Care, including adolescents, youth, people with disabilities, and other vulnerable groups Priority Actions / interventions1. Increase skilled care at community level during pregnancy, childbirth, postpartum
and the newborn period 2. Enhance the capacity of health facilities to provide Essential Maternal and
Newborn Care 3. Strengthen human resources for Maternal and Newborn Health 4. Strengthen the integration of HIV/AIDS information and services into Maternal
and Newborn Health services at all levels of health care. 5. Institutionalise quality of care approaches. 6. Scale up efficient healthcare financing mechanisms for Maternal and Newborn
Health 7. Increase access to Maternal and Newborn Health information and services with
special emphasis on adolescents, youth, and other vulnerable groups
Strategy 5: Reduce unmet need through expanding access to good quality family planning options for sexually active men, women, adolescents and persons with disabilities Priority Actions / interventions 1. Increase access to postpartum family planning. 2. Advocate contraceptive commodity security. 3. Promote participation of communities and the private sector in provision of FP
services. 4. Strengthen integration of FP and HIV services.
Strategy 6: Strengthening the referral system.Priority Actions / interventions 1. Lobby for a strengthened transport and referral system. 2. Establish community-based mechanisms to promote timely referral. 3. Strengthen communication between different levels of care by use of modern
technologies
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Strategy 7: Advocating for increased commitment and resources for MNH and FP services Priority Actions / interventions 1. Strengthen resource mobilisation for Maternal and Newborn Health. 2. Advocate for incorporation of MNH requirements in all National Policy and
Strategy documents
Strategy 8: Fostering partnerships 1. Coordinate MNH stakeholders at national, provincial, district and community
level 2. Strengthen and sustain Public Private Partnerships for MNH
Objective 3 To strengthen the capacity of individuals, families, communities, social networks to improve maternal and newborn health
Strategy 9: Strengthening community based maternal and newborn care approaches Priority Actions / interventions 1. Promoting the household hospital continuum of care. 2. Operationalize the MNH aspects in line with the National Community Strategy
principles. 3. Strengthening knowledge and awareness of communities on MNH services
including family planning. 4. Support community based initiatives that promote MNH.
Monitoring and Evaluation of Maternal and Newborn Health Monitoring and evaluation remains a key challenge of MNH programmes. The M&E system for maternal and newborn health will aim at generating information that will be used for evidence-based decision making and the planning process. The National MNH Road Map will endeavour to meet the targets outlined in the MDGs and the health sector strategic plans. The following are the key indicators and their targets.
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No. Indicators BaselineTarget 2010
Target 2015
Source of data
1Maternal Mortality Ratio/ 100 000 live births 488 280 147
KDHS 2008/09
2Neonatal Mortality Rate/ 1 000 live births 31 21 11
KDHS 2008/09
3Proportion of facilities providing BEONC 9% 50% 100% KSPA 2004
4aAvailability of CEmOC / 500 000 population 1.3 1.3 1 KSPA 2004
4bAvailability of BEmOC / 500 000 population 0.4 2.2 4 KSPA 2004
4cTotal availability of EmOC/ 500 000 population 1.7 3.4 5 KSPA 2004
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Proportion of (expected) deliveries in the population conducted by a skilled attendant 43.8% 67% 90%
HMIS KDHS 2008/09
6
Proportion of pregnant women having at least one antenatal visits during this pregnancy 91.5% 96% 100%
KDHS 2008/09
7
Proportion of pregnant women having at least four antenatal visits during this pregnancy 52% 71% 90%
HMIS KDHS 2003
8Proportion of antenatal women receiving IPT2 15% 47.5% 80%
KDHS 2008/09
9
Percentage of women attending post¬natal care check up at least once within 2 weeks 2%
HMIS KDHS 2003
10Proportion of pregnant women attending ANC tested for HIV 57% 68.5% 80% KAIS 2007
11 Unmet need for contraception 24% 12% 0%KDHS 2003
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Roles and Responsibilities
The successful implementation of this Road Map will be guided by the framework stipulated in the National Health Strategic Plans, National Reproductive Health Policy (2007) and Child Survival and Development Strategy (2008). This Road Map will be implemented at different levels as outlined in the RH policy - the National level through the DRH; at Provincial and District levels through the Provincial and District Management Teams and Boards; and at the Community level through the Village and Health Facility Committees.
Ministries of Public Health & Sanitation and Medical Services The Ministries of Public Health & Sanitation (MOPHS) and Medical Services (MOMS) will oversee and facilitate the implementation of this Road map. The MOPHS/MOMS will:• Ensure the creation of an enabling environment for the implementation of key
activities. • Ensure that health facilities have adequate capacity in terms of staffing,
equipment and supplies to adequately provide quality services. • Strengthen health systems to deliver quality maternal and newborn care. • Allocate necessary resources using existing national initiatives for the
implementation of the Road Map. • Establish mechanisms for supervision and ensure regular monitoring and
evaluation of progress made by Development partners. • Mobilise and provide technical and financial support for the planning,
implementation monitoring and evaluation. • Advocate for increased national commitment to the reduction of maternal and
newborn morbidity and mortality.
Roles of NGOs, CBOs, FBOs and Private sector • These organisations will be encouraged to expand coverage and improve access
to MNH services. • Advocate for and promote the rights of women and children and the need to
address their problems. • Mobilise and allocate resources for MNH programmes.• Implement community based strategies to promote healthy behaviour during
pregnancy, childbirth and postpartum period.
Communities, Households and Individuals • Communities will participate through the health facility committees, and village
health committees as well as community health extension workers in resource mobilisation, planning, monitoring and evaluation of MNH services.
• Households and individuals will be encouraged to participate and contribute towards improvement of MNH.
17
August 2010
National Road Map
Role of Training Institutions • The approved university based medical and nursing schools, the Kenya Medical
Training Colleges, and the private and mission medical training hospitals will be expected to regularly update and incorporate MNH into their curriculum.
Role of Research Institutions • To regularly conduct MNH operations research and disseminate findings to all
stakeholders. • To assist the MOH to translate research findings into programming and service
delivery.
Role of Parliamentarians • Speak out in parliament and publicly for MDGs 4 & 5.• Liaise regularly with constituents to educate them on MDGs 4 & 5 and seek
training to do that effectively.• Undertake a review of existing laws to eliminate legal obstacles that limit
women’s access to health care services. • Liaise or work with the budget/finance committee in parliament, paying particular
attention to health issues and MDGs 4 & 5. • Raise awareness in constituencies and hold debates on harmful traditional
practices
18
August 2010
National Road Map
Stra
tegi
esPr
iorit
y A
ctio
nsB
road
act
iviti
esIn
dica
tors
Targ
ets
Est
imat
ed
cost
09/1
010
/11
11/1
2
Stra
tegy
1:
Stre
ngth
en
Mon
itorin
gan
d Ev
alua
tion
syst
emfo
r Mat
erna
l and
New
born
Hea
lth
1.1
Stre
ngth
en M
NH
dat
am
anag
emen
t and
ut
ilisa
tion
at a
ll le
vels
1.1.
1 O
pera
tiona
lise
Nat
iona
l R
epro
duct
ive
Hea
lth M
&E
fram
ewor
k at
al
l lev
els
No.
of p
rovi
ncia
l dis
sem
inat
ion
mee
tings
44
No.
of d
istri
cts
that
sub
mit
mon
thly
RH
re
ports
, inc
ludi
ng d
ata
from
priv
ate
sect
or10
015
020
0
1.1.
2 C
ondu
ct re
gula
r per
form
ance
re
view
mee
tings
for M
NH
with
st
akeh
olde
rs, a
t all
leve
ls
No.
of r
evie
w m
eetin
gs a
t nat
iona
l, pr
ovin
cial
and
dis
trict
leve
lqu
arte
rlyqu
arte
rlyqu
arte
rly
1.1.
3 E
valu
ate
Roa
d M
ap
impl
emen
tatio
n in
201
2 an
d 20
15M
idte
rm e
valu
atio
n co
nduc
ted
to m
easu
re
impl
emen
tatio
n of
the
Roa
d M
apm
idte
rm
1.2
Adv
ocat
e fo
r in
clus
ion
of M
NH
in
dica
tors
in a
ll th
e su
rvey
s an
d ro
utin
e da
ta
colle
ctio
n to
ols
1.2.
1 P
artic
ipat
e in
dev
elop
men
t of d
ata
colle
ctio
n to
ols
for r
elev
ant s
urve
ysN
o. o
f sur
vey
data
col
lect
ion
tool
s w
ith
MN
H in
dica
tors
incl
uded
cens
us,
KS
PAK
AIS
MIS
1.2.
2.C
ondu
ct M
NH
sur
veys
No.
of s
urve
ys c
ondu
cted
12
1.2.
3 A
naly
se, d
isse
min
ate,
and
util
ise
data
find
ings
from
sur
veys
and
rout
ine
serv
ice
deliv
ery
No.
of s
urve
y an
d H
MIS
repo
rtsw
ith M
NH
dat
a2
22
No.
of m
eetin
gs w
here
MN
H d
ata
is b
eing
di
ssem
inat
ed4
44
No.
of d
ocum
ents
that
sho
w tr
ansl
atio
n of
fin
ding
s in
to d
ecis
ion
mak
ing
24
8
Stra
tegy
2:
Stre
ngth
en
oper
atio
nsre
sear
ch in
Mat
erna
lan
d N
ewbo
rn H
ealth
2.1
Stre
ngth
en
linka
ges
betw
een
MN
H s
take
hold
ers
and
rese
arch
and
trai
ning
in
stitu
tions
2.1.
1 R
evie
w a
nd im
plem
ent M
NH
rese
arch
age
nda
No.
of M
NH
rese
arch
topi
cs b
eing
com
plet
ed4
68
2.1.
2 O
pera
tiona
lise
MN
H re
sear
ch
guid
elin
esN
o. o
f res
earc
h pr
opos
als
bein
g re
view
ed
by re
sear
ch T
WG
24
2.2
Pro
mot
e th
e do
cum
enta
tion,
diss
emin
atio
n an
d ut
ilisa
tion
of e
vide
nce-
base
d pr
actic
es
2.2.
1 A
dvoc
ate
for i
ncre
ased
fund
ing
for
MN
H re
sear
ch.
Pro
porti
on o
f ann
ual b
udge
t spe
nd o
n M
NH
rese
arch
2%3%
4%
2.2.
2 R
egul
arly
doc
umen
t and
sha
re
best
pra
ctic
es in
MN
HN
o. o
f for
a w
here
bes
t pra
ctic
es in
MN
H
are
bein
g sh
ared
48
8
2.2.
3 D
isse
min
ate
rese
arch
upd
ates
to
prom
otet
rans
latio
n of
rese
arch
find
ings
in
to M
NH
pol
icie
s an
d pr
ogra
mm
ing
No.
of M
NH
pol
icie
s an
d pr
ogra
mm
es th
at
inco
rpor
ate
best
pra
ctic
es /
rese
arch
find
ings
24
6
Stra
tegy
3:
Stre
ngth
enin
gna
tiona
l, pr
ovin
cial
an
d di
stric
t hea
lth
plan
ning
and
m
anag
emen
t of
MN
H c
are
3.1
Stre
ngth
en c
apac
ity
of th
e na
tiona
l, pr
ovin
cial
an
d di
stric
t man
ager
s,
in h
ealth
pla
nnin
g,
man
agem
ent a
nd
faci
litat
ive
supe
rvis
ion
3.1.
1 C
ondu
ct re
gula
r tra
inin
gs /u
pdat
es
for m
anag
ers
in M
NH
pla
nnin
g an
d su
perv
isio
n
No.
of m
anag
ers
train
ed a
nd/o
r upd
ated
in
MN
H p
lann
ing
and
prog
ram
min
g40
8012
0
No.
of f
acili
tativ
e su
perv
isio
n vi
sits
on
MN
H c
ondu
cted
by
natio
nal l
evel
24
6
3.2
Stre
ngth
en jo
int
prog
ram
min
g be
twee
n M
NH
and
rela
ted
prog
ram
mes
to m
axim
ise
reso
urce
s
3.2.
1 P
artic
ipat
e in
AO
P pl
anni
ng
guid
elin
es a
nd p
roce
sses
at a
ll le
vels
to
ensu
re in
clus
ion
of M
NH
prio
ritie
s
No.
of d
istri
ct A
OP
s th
at h
ave
incl
uded
co
mpr
ehen
sive
MN
H a
ctiv
ities
100
150
200
19IM
PLE
MEN
TATI
ON
FR
AM
EWO
RK
August 2010
National Road MapN
o of
ser
vice
pro
vide
rs s
ensi
tised
on
RH
ne
eds
of P
WD
4000
8000
1200
4.4
Stre
ngth
en th
e in
tegr
atio
n of
HIV
/AID
S
info
rmat
ion
and
serv
ices
in
to M
ater
nal a
ndN
ewbo
rn H
ealth
ser
vice
sat
all
leve
ls o
f hea
lth c
are
4.4.
1 Im
plem
ent H
IV/M
NH
inte
grat
ion
prot
ocol
s ( P
MTC
T gu
idel
ines
; RH
/HIV
Inte
grat
ion
stra
tegy
, KN
AS
P 3)
No
of fa
cilit
ies
impl
emen
ting
RH
/HIV
inte
grat
ed s
ervi
ces
as re
com
men
ded
in th
e R
H/H
IV in
tegr
atio
n st
rate
gy20
0030
0040
00
4.4.
2 C
ondu
ct R
H/H
IV in
tegr
atio
n pr
ogra
mm
e ev
alua
tion
No
of e
valu
atio
ns c
ondu
cted
24
4
4.5
Inst
itutio
nalis
e qu
ality
of
car
eap
proa
ches
4.5.
1 R
evie
w a
nd u
pdat
e gu
idel
ines
, st
anda
rds
and
train
ing
mat
eria
ls fo
r MN
HN
o. o
f upd
ated
doc
umen
ts fi
naliz
ed
MN
Htra
inin
gpa
ckag
e,gu
idel
ines
4.5.
2 S
treng
then
/revi
talis
e Q
A co
mm
ittee
s fo
r MN
H in
all
faci
litie
sN
o of
faci
litie
s w
ith fu
nctio
nal Q
A co
mm
ittee
s15
0030
0050
00
4.5.
3 E
stab
lish
mat
erna
l and
per
inat
alde
ath
revi
ews
at a
ll le
vels
No
of m
ater
nal d
eath
s no
tified
ann
ually
400
1200
3000
No
of d
istri
cts
subm
ittin
g qu
arte
rlyM
DR
repo
rts40
8012
0
No
of fa
cilit
ies
cond
uctin
g pe
rinat
al d
eath
re
view
s10
020
040
0
4.5.
4 Lo
bby
for l
egis
latio
n of
Mat
erna
l D
eath
not
ifica
tion
MD
not
ifica
tion
gaze
tted
x
4.6
Sca
le u
p ef
ficie
nt
heal
thca
refin
anci
ng m
echa
nism
s fo
r M
ater
nal
and
New
born
Hea
lth
4.6.
1 A
dvoc
ate
for h
ealth
fina
ncin
g m
echa
nism
s th
atin
crea
se a
cces
s to
and
upt
ake
of M
NH
se
rvic
es (N
HIF
, HS
SF,
Med
ical
ser
vice
s fu
nds,
insu
ranc
e in
dust
ry, D
eman
dsi
de fi
nanc
ing
etc
)
No
of in
sura
nce
com
pani
es th
at o
ffer
com
preh
ensi
ve M
NH
cov
er in
clud
ing
FP4
68
Pro
porti
on o
f HS
SF
fund
s th
at is
use
d to
stre
ngth
en M
NH
ser
vice
s20
%30
%40
%
Cre
atio
n of
bud
get l
ine
for M
NH
x
Pro
porti
on o
f par
tner
fund
s co
mm
itted
to M
NH
??
?
4.6.
2 S
cale
up
dem
and
side
fina
ncin
g fo
r M
NH
ser
vice
s
No
of fa
cilit
ies
that
pro
vide
sub
sidi
sed
MN
H s
ervi
ces
unde
r dem
and
side
fin
anci
ng s
chem
e40
100
200
4.7
Incr
ease
acc
ess
to
Mat
erna
l and
New
born
H
ealth
info
rmat
ion
and
serv
ices
with
spe
cial
em
phas
is o
n ad
oles
cent
s &
you
th, a
nd o
ther
vu
lner
able
gro
up
4.7.
1 D
evel
ope
and
diss
emin
ate
MN
H
IEC
/BC
C m
ater
ials
and
mes
sage
sN
o. o
f IE
C m
ater
ials
dev
elop
ed a
nddi
ssem
inat
ed10
1520
4.7.
2. S
ensi
tise
serv
ice
prov
ider
s on
M
NH
serv
ice
prov
isio
n to
PW
Ds
No.
of s
ervi
ce p
rovi
ders
that
are
com
pete
nt to
pro
vide
com
preh
ensi
veM
NH
ser
vice
s to
PW
D50
090
015
00
Stra
tegy
5: R
educ
eun
met
nee
d th
roug
h ex
pand
ing
acce
ss to
go
od q
ualit
y fa
mily
plan
ning
opt
ions
for
sexu
ally
act
ive
men
, w
omen
, ado
lesc
ents
and
pers
ons
with
di
sabi
litie
s
5.1
Incr
ease
acc
ess
topo
stpa
rtum
Fam
ily
Pla
nnin
g
5.1.
1 S
ensi
tise
com
mun
ities
and
hea
lthw
orke
rs o
n P
ost P
artu
m C
are
Pro
porti
on o
f pre
gnan
t wom
enre
ceiv
ing
at le
ast o
nce
post
nata
lcar
e20
%40
%60
%
5.1.
2 S
cale
up
post
par
tum
FP
No
of w
omen
rece
ivin
g FP
dur
ing
post
partu
m p
erio
d50
0,00
075
0,00
01,
000,
000
20
August 2010
National Road Map
5.2
Adv
ocat
e fo
r co
ntra
cept
ive
com
mod
ity
secu
rity
5.2.
1 Im
plem
ent c
ontra
cept
ive
com
mod
ity s
ecur
ity s
trate
gyN
o. o
f dis
trict
s w
ithou
t sto
ck o
uts
of F
Pco
mm
oditi
es in
the
past
3 m
onth
s10
015
020
0
5.2.
2 lo
bby
for a
ddito
nal r
esou
rces
for F
P co
mm
oditi
esA
nnua
l GO
K a
lloca
tion
for p
rocu
rem
ent
of F
P co
mm
oditi
es50
0M60
0M70
0M
5.3
Pro
mot
e pa
rtici
patio
n of
com
mun
ities
and
the
priv
ate
sect
or in
pro
visi
on
of F
P se
rvic
es
5.3.
1 S
cale
up
prov
isio
n of
FP
serv
ices
at c
omm
unity
leve
lN
o of
CH
Ws
and
CM
s pr
ovid
ing
FP s
ervi
ces
20,0
0060
,000
120,
000
5.3.
2 S
ocia
l mar
ketin
g an
d fra
nchi
sing
of
Fam
ily P
lann
ing
serv
ices
No
of p
rivat
e fa
cilit
ies
prov
idin
g FP
serv
ices
??
?
5.3.
4 A
dvoc
acy
for r
epos
ition
ing
of F
P at
all
leve
lsN
o of
nat
iona
l FP
cam
paig
ns1
22
5.4
Stre
ngth
en in
tegr
atio
n of
FP
and
HIV
ser
vice
s5.
4.1
Sca
le u
p in
tegr
atio
n of
FP
and
HIV
No
of fa
cilit
ies
prov
idin
g in
tegr
ated
FP/H
IV s
ervi
ces
2000
3000
4000
Stra
tegy
6:
Stre
ngth
enin
gth
e re
ferr
alsy
stem
6.1
Lobb
y fo
r a
stre
ngth
ened
tran
spor
t an
d re
ferr
al s
yste
m
6.1
Adv
ocat
e fo
r fina
lizat
ion
and
oper
atio
nalis
atio
n of
nat
iona
l ref
erra
l st
rate
gy
No
of p
rovi
nces
whe
re re
ferr
al s
trate
gy
has
been
dis
sem
inat
ed4
4
6.2
Ens
ure
that
acc
ess
to E
mer
genc
y O
bste
tric
care
is a
ddre
ssed
in th
e N
atio
nal T
rans
port
and
Ref
erra
l Stra
tegy
No
of d
istri
cts
that
hav
e a
refe
rral
sy
stem
in p
lace
resp
onsi
ve to
obs
tetri
c em
erge
ncie
s60
120
180
6.2
Est
ablis
h co
mm
unity
-ba
sed
mec
hani
sms
topr
omot
e tim
ely
refe
rral
6.2.
1 E
stab
lishm
ent o
f fun
ctio
nal
com
mun
ity u
nits
No
of fu
nctio
nal c
omm
unity
uni
ts10
0025
0040
00
6.2.
2 S
uppo
rt es
tabl
ishm
ent o
f co
mm
unity
tran
spor
t ini
tiativ
es (e
.g.
revo
lvin
g fu
nd)
Pro
porti
on o
f com
mun
ity u
nits
with
esta
blis
hed
and
func
tiona
l ref
erra
l sy
stem
5%10
%20
%
6.3
Stre
ngth
en
com
mun
icat
ion
betw
een
diffe
rent
leve
ls
of c
are
by u
se o
f mod
ern
tech
nolo
gies
6.3.
1 S
cale
up
avai
labi
lity
of
com
mun
icat
ion
at a
ll le
vels
Pro
porti
on o
f fac
ilitie
s w
ithfu
nctio
nal c
omm
unic
atio
n60
%75
%90
%
6.3.
2 E
xpan
d th
e av
aila
bilit
y of
te
lem
edic
ine
at a
ll le
vels
No
of d
istri
cts
that
hav
e ac
cess
tote
lem
edic
ine
2040
60
Stra
tegy
7:
Adv
ocat
ing
for i
ncre
ased
com
mitm
ent
and
reso
urce
sfo
r MN
Han
d FP
ser
vice
s
7.1
Stre
ngth
en re
sour
cem
obili
satio
n fo
r Mat
erna
lan
d N
ewbo
rn H
ealth
7.1.
1 A
dvoc
ate
with
MO
F to
incr
ease
bu
dget
allo
catio
n fo
r MN
H b
y ac
tivel
y pa
rtici
patin
g in
MTP
and
MTE
F, e
tc
No
of n
atio
nal b
udge
ts th
at h
ave
incr
ease
d re
sour
ces
allo
cate
d fo
rM
NH
MTE
F,
MTP
MTE
F, M
TPM
TEF,
M
TP
7.1.
2 M
NH
pro
gram
me
man
ager
s to
par
ticip
ate
in g
loba
l res
ourc
e m
obili
satio
n fo
rum
s e.
g G
loba
l fun
d
No
of g
loba
l pro
posa
ls th
at in
clud
eM
NH
glob
alfu
ndP
EP
FAR
GAV
I
7.2
Adv
ocat
e fo
r in
corp
orat
ion
of M
NH
re
quire
men
ts in
all
Nat
iona
l Pol
icy
and
Stra
tegy
doc
umen
ts
7.2.
1 D
isse
min
ate
and
impl
emen
tN
atio
nal R
H s
trate
gyN
o of
dis
trict
s th
at a
re im
plem
entin
gth
e na
tiona
l RH
stra
tegy
4080
120
7.2.
2 Fa
cilit
ate
inco
rpor
atio
n of
MN
H
issu
es in
the
revi
sion
of r
elev
ant p
olic
ies
and
stra
tegi
es (K
NA
SP,
Mal
aria
stra
tegy
, H
SS
Ps,
etc
)
No
of h
ealth
pol
icie
s an
d st
rate
gies
that
out
line
MN
H p
riorit
ies
HS
SP
IIIH
ealth
polic
yfra
mew
ork
2012
- 20
16st
rate
gies
Stra
tegy
8:
Fost
erin
gpa
rtne
rshi
ps
8.1
Coo
rdin
ate
MN
H
stak
ehol
ders
at n
atio
nal,
prov
inci
al, d
istri
ct a
nd
com
mun
ity le
vel
8.1.
1 E
nsur
e th
at M
NH
issu
es a
re w
ell
artic
ulat
ed a
nd c
oord
inat
ed w
ithin
the
gove
rnm
ent s
truct
ures
and
SW
AP
at a
ll le
vels
No
of p
artn
ers
that
sup
port
impl
emen
tatio
nof
AO
P M
NH
act
iviti
es w
ithin
exi
stin
ggo
vern
men
t stru
ctur
es
??
?
21
August 2010
National Road Map
8.2
Stre
ngth
en a
nd
sust
ain
Pub
licP
rivat
e P
artn
ersh
ips
for
MN
H
8.2.
1 C
ondu
ct jo
int p
lann
ing
and
revi
ew
mee
tings
for
MN
H
No
of d
istri
cts
with
act
ive
and
func
tiona
l pub
lic p
rivat
e pa
rtner
ship
fo
r MN
H s
ervi
cede
liver
y
1020
40
Stra
tegy
9:
Stre
ngth
enin
gco
mm
unity
ba
sed
mat
erna
lan
d ne
wbo
rn
care
appr
oach
es
9.1
Pro
mot
ing
the
hous
ehol
d ho
spita
lco
ntin
uum
of c
are
9.1.
1 C
omm
unic
ate
the
rede
fined
role
s of
Tra
ditio
nal B
irth
Atte
ndan
ts to
the
com
mun
ities
, TB
As
and
stak
ehol
ders
No
of d
istri
cts
in w
hich
the
rede
fined
ro
le o
f TB
As
has
been
effe
ctiv
ely
com
mun
icat
ed60
120
200
9.1.
2 E
stab
lish
Mat
erni
ty W
aitin
g H
omes
in
nee
dy a
reas
No
of m
ater
nity
wai
ting
hom
es
esta
blis
hed
and
func
tiona
l20
4060
9.1.
3 P
rovi
de M
NH
out
reac
h se
rvic
esAv
erag
e no
. of M
NH
out
reac
hes
prov
ided
per
dis
trict
46
8
9.2
Ope
ratio
naliz
e th
e M
NH
asp
ects
inlin
e w
ith th
e N
atio
nal
Com
mun
ityS
trate
gy p
rinci
ples
9.2.
1 O
rient
CH
Ws,
Loc
al a
dmin
istra
tion
and
com
mun
ity le
ader
s on
com
mun
ity
MN
H
No
of d
ivis
ions
whe
re lo
cal
adm
inis
tratio
n is
sen
sitis
ed o
n M
NH
500
1000
1500
9.2.
2 S
uppo
rt C
HE
Ws
in im
plem
entin
g co
mm
unity
bas
ed M
NH
No
of d
istri
cts
that
are
rolli
ng o
utco
mm
unity
bas
ed M
NH
ser
vice
s40
8012
0
No
of C
Us
that
hav
e be
en tr
aine
d on
com
mun
ity M
NH
500
1000
1500
9.3
Stre
ngth
enin
g kn
owle
dge
and
awar
enes
s of
co
mm
uniti
es o
n M
NH
serv
ices
incl
udin
g fa
mily
pl
anni
ng
9.3.
1 D
evel
ope
coho
rt 1
mes
sage
s fo
r di
ffere
nt c
hann
els
of c
omm
unic
atio
nN
o of
mes
sage
s de
velo
ped
pam
phet
s,po
ster
s,
job
aids
mas
sm
edia
SM
S,
eHea
lth
9.3.
2 C
ondu
ct a
dvoc
acy
and
awar
enes
s ca
mpa
igns
for
MN
H w
ith k
ey m
essa
ges
at c
omm
unity
le
vel
No
of d
istri
cts
that
con
duct
adv
ocac
y an
d aw
aren
ess
cam
paig
ns a
t co
mm
unity
leve
l at l
east
onc
e a
year
5010
020
0
9.4
Sup
port
com
mun
ity
base
d in
itiat
ives
that
pr
omot
e M
NH
9.4.
2 In
stitu
te b
irth
prep
ared
ness
pla
ns a
t co
mm
unity
leve
l esp
ecia
lly fo
r ver
y yo
ung
adol
esce
nts
No.
of C
Us
that
act
ivel
y fo
llow
up
on
birth
pre
pare
dnes
s40
080
012
00
9.4.
3 E
stab
lish
soci
al in
sura
nce
syst
ems
at lo
cal l
evel
No
of C
Us
with
soc
ial i
nsur
ance
sy
stem
in p
lace
4080
120
22
August 2010
National Road Map
REFERENCES
FCI (2007). Safe Motherhood. A Review: The Safe Motherhood Initiative 1987-2005. Family Care International
Jones, G. et al. (2003). How Many Child Deaths can we prevent this Year? The Lancet, 362, 65–71. KNBS, MOH and ORC Macro (2003). Kenya Demographic and Health Survey 2003. Kenya National Bureau of Statistics, Ministry of Health and ORC Macro.
KNBS, MOH and ORC Macro (2004). Kenya Service Provision Assessment
(KSPA) 2004. Kenya National Bureau of Statistics, Ministry of Health and ORC Macro.
Melngailis, I. (2006). Challenging Myths and Barriers to IUD Use: The “Truth” Campaign Support to the MOH IUD Re-Introduction Initiative in Kisii District, Kenya. The ACQUIRE Project 1 March 2006. MOH (2005). The Second National Health Sector Strategic Plan of Kenya (NHSSP II) 2005-2010– Reversing the Trends. Ministry of Health
MOH (2006). Situation Analysis of Adolescent Reproductive Health and Stakeholder Analysis in Nyanza Province. Ministry of Health, Division of Reproductive Health
MOH (2007). National Reproductive Health Policy. Enhancing Reproductive Health Status for all Kenyans. Ministry of Health, Division of Reproductive Health.
PEPFAR (2008). Prevention of Mother to Child Transmission. Retrieved 30 November 2008, from http://www.pepfar.gov/ documents/organization/79663.pdf.
PRB (2007). Evaluating Stillbirths. Improving Still Births Data Could Help Make Stillbirths a Visible Public Health Priority. Population Reference Bureau.
NASCOP and MOH Kenya (2008). Kenya AIDS Indicator Survey (KAIS) 2007. Preliminary Report. National AIDS and STI Control Programme and Ministry of Health.
Lawn, J. and Kerber, K (2006), eds. Opportunities for Africa’s Newborns: Practical Data, Policy and Programmatic Support for Newborn Care in Africa. The Partnership for Maternal, Newborn and Child Health (PMNCH).
The Lancet Child Survival Series, 2003 Reynolds, H. and Wilcher, R. (2006). Best Kept Secret in PMTCT: Contraception to Avert Unintended Pregnancies. AIDS Link (97): 8-9
UNDP (2005). Population, Reproductive Health and the Millennium Development Goals. Message from the UN Millennium Project Report. United Nations Development Programme
23
August 2010
National Road Map
UNDP (2005). UN Millennium Project. 2005. Investing in Development: A Practical Plan to Achieve the Millennium Development Goals. United Nations Development Programme
UNDP et al. (2006). Causes of Maternal Death. A Systematic Review. The Lancet 2006; 367:1066-74 UNDP, UNFPA, World Bank and WHO.
Warren, C. and Liambila W. (2004). Approaches to Providing Quality Maternal Care in Kenya, Safe Motherhood Demonstration Project.MOH Ministry of Health, Division of Reproductive Health and University of Nairobi.
Wesson et al. (2006). Effect of a Provider Based Educational Outreach (“Detailing”) to Stimulate IUCD in Kenya.
WHO (2005). The World Health Report 2005 - Make Every Mother and Child Count. World Health Organization.
WHO (2007). Neonatal and Perinatal Mortality. Country, Regional and Global Estimates 2004. World Health Organization.
WHO (2008). Road Map for Accelerating the Attainment of Millennium Development Goals Related to Maternal and Newborn Health in Africa. World Health Organization.
24
August 2010
National Road Map25
Annex 1: Millennium Development Goals and Targets
1 Eradicate extreme poverty and hunger (i) Halve, between 1990 and 2015, the proportion of people whose income is less than $1 a day. (i) Halve, between 1990 and 2015, the proportion of people who suffer from hunger.
2 Achieve universal primary education (i) Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling.
3 Promote gender equality and empower women (i) Eliminate gender disparity in primary and secondary education, preferably by 2005, and at all levels of education no later than 2015.
4 Reduce child mortality (i) Reduce by two thirds, between 1990 and 2015, the under-five mortality rate.
5 Improve maternal health (i) Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
• Maternal mortality ratio • Proportion of births attended by skilled health personnel 5B: Achieve by 2015, universal access to reproductive health • Contraceptive prevalence rate • Adolescent birth rate • Antenatal coverage • Unmet need for family planning
6 Combat HIV/AIDS, malaria and other diseases (i) Have halted by 2015 and begun to reverse the spread of HIV/AIDS. (ii) Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases.
7 Ensure environmental sustainability (i) Integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources.(ii) Halve, by 2015, the proportion of people without sustainable access to safe drinking- water and basic sanitation. (iii) Have achieved, by 2020, a significant improvement in the lives of at least 100 million slum dwellers.
August 2010
National Road Map26
8 Develop a global partnership for development
(i) Develop further an open, rule-based, predictable, non-discriminatory trading and financial system (includes a commitment to good governance, development and poverty reduction - both nationally and internationally). (ii) Address the special needs of the least developed countries (includes tariff-and quota-free access for exports enhanced programme of debt relief for heavily indebted poor countries and cancellation of official bilateral debt, and more generous official development assistance for countries committed to poverty reduction). (iii) Address the special needs of landlocked countries and small island developing states (through the Programme of Action for the Sustainable Development of Small Island Developing States and the outcome of the twenty-second special session of the General Assembly). (iv) Deal comprehensively with the debt problems of developing countries through national and international measures in order to make debt sustainable in the long term. (v) In cooperation with developing countries, develop and implement strategies for decent and productive work for youth. (vi) In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries. (vii) In cooperation with the private sector, make available the benefits of new technologies, especially information and communications.
August 2010
National Road Map27
Leve
l 1Le
vel 2
Leve
l 3Le
vel 4
, 5 a
nd 6
Pro
mot
ion
of h
ealth
ybe
havi
ours
incl
udin
g:•
Mal
e in
volv
emen
t•
Ear
ly a
nten
atal
at
tend
ance
• In
divi
dual
Birt
h P
lan
• S
kille
d B
irth
Atte
ndan
ce•
Nut
ritio
nal c
are
• E
arly
pos
tpar
tum
and
ne
wbo
rn c
are
• Im
mun
isat
ion
• E
arly
initi
atio
n an
d ex
clus
ive
brea
stfe
edin
g•
Mal
aria
pre
vent
ion
• P
MTC
T•
FP s
ervi
ces
• H
ygie
ne•
Birt
h an
d de
ath
notifi
catio
n•
Mot
her &
Chi
ld H
ealth
B
ookl
et
Rec
ogni
tion
of d
ange
r sig
ns
for
mot
her a
nd b
aby
that
requ
irere
ferr
al
Est
ablis
hmen
t of
com
mun
ityba
sed
refe
rral
sys
tem
for
emer
genc
ies
Est
ablis
hmen
t of c
omm
unity
base
d FP
dis
tribu
tion
netw
ork
All
leve
l 1 s
ervi
ces
plus
Focu
sed
Ant
enat
al C
are
(FA
NC
)•
Cou
nsel
on
dang
er s
igns
and
em
erge
ncy
prep
ared
ness
• In
divi
dual
Birt
h P
lan
• TT
imm
uniz
atio
n•
MIP
(IP
T, IT
N)
• Iro
n/fo
lic s
uppl
emen
t•
De-
wor
min
g•
Syp
hilis
scr
eeni
ng•
PM
TCT
• TB
scr
eeni
ng (c
linic
al)
• Id
entifi
catio
n of
com
plic
atio
ns
and
man
agem
ent a
nd/o
r ap
prop
riate
refe
rral
Nor
mal
labo
ur a
nd d
eliv
ery
• U
se o
f par
togr
aph
• S
VD
• A
MTS
L•
Iden
tifica
tion
of c
ompl
icat
ions
an
d m
anag
emen
t•
and/
or a
ppro
pria
te re
ferr
al•
PM
TCT
Ess
entia
l New
born
Car
e (E
NC
)•
Kee
ping
the
baby
war
m
incl
udin
g K
anga
roo
Mot
her
Car
e•
Ear
ly in
itiat
ion
of
brea
stfe
edin
g•
Cou
nsel
mot
her a
nd fa
mily
on
dan
ger s
igns
of t
he
new
born
All
leve
l 2 s
ervi
ces
plus
Focu
sed
Ant
enat
al C
are
(FA
NC
)•
Full
ante
nata
l pro
file
• S
putu
m fo
r AA
FB
Bas
ic E
ssen
tial O
bste
tric
Car
e (B
EO
C)
• P
aren
tera
l oxy
toci
cs to
aug
men
t•
labo
ur o
r man
agem
ent o
f PP
H•
Par
ente
ral a
ntib
iotic
s to
trea
t•
puer
pera
l and
new
born
infe
ctio
ns•
Par
ente
ral a
ntic
onvu
lsan
ts
(MgS
O4)
to m
anag
e (p
re)
ecla
mps
ia•
Man
ual r
emov
al o
f pla
cent
a•
Man
ual V
acuu
m A
spira
tion
for
inco
mpl
ete
abor
tion
• A
ssis
ted
vagi
nal d
eliv
ery
(vac
uum
ex
tract
ion)
• N
eona
tal r
esis
cita
tion
• E
ssen
tial N
ewbo
rn C
are
(EN
C)
• O
xyge
n th
erap
y
All
leve
l 3 s
ervi
ces
plus
Focu
sed
Ant
enat
al C
are
(FA
NC
)•
CD
4 co
unt
• R
hesu
s in
com
patib
ility
• U
ltras
ound
Com
preh
ensi
ve E
ssen
tial
bste
tric
Car
e (C
EO
C)
• 7
BE
OC
sig
nal f
unct
ions
• B
lood
tran
sfus
ion
• S
urgi
cal p
roce
dure
s (e
.g.
C/s
ectio
n, L
apar
atom
y fo
r E
ctop
ic p
regn
ancy
or r
uptu
red
uter
us, d
estru
ctiv
e va
gina
l op
erat
ion,
D&
C)
Ann
ex I
I: M
inim
um P
acka
ge o
f M
NH
Ser
vice
s by
KEP
H L
evel
August 2010
National Road Map28
Annex III: Policy Guidelines, Frameworks and Standards Developed to Guide the Implementation of SRH Programmes in Kenya
Policy • MOH/DRH (2007): National Reproductive Health Policy • NCPD (MPND)/DRH/MOH (2003): Adolescent Reproductive Health and Development Policy
Plans of Action • GOK/NACC (2003). Mainstreaming Gender into the Kenya National HIV/ AIDS Strategic Plan 2000-2003. • MOH/DRH (1999). National Plan of Action for the Elimination of Female Genital Mutilation in Kenya 1999 – 2019.• MOH: National PMTCT Strategic Plan 2003-2007. • MOH/DRH (2005). National Cervical Cancer Prevention Plan 2005-2009.
Guidelines / Framework • MOH/DRH (2002). National Guidelines for Quality Obstetrics and Perinatal Care. • MOH/ DRH (2005). Family Planning Guidelines for Service Providers. • MOH/DRH (2004). National Guidelines: Medical Management of Rape and Sexual Violence. • MOH/NASCOP (2009). National Guidelines: Prevention of Mother to Child HIV/AIDS Transmission. • MOH/DRH (2005). National Guidelines for Provision of Youth Friendly Services (YFS) in Kenya. • MOH/DRH (2002). Standards for Maternal Care in Kenya. • MOH/DRH (2002). Essential Obstetric Care Manual for Health Service Providers in Kenya: A Safe Motherhood Initiative.
Strategy papers • MOH/DRH (2009). National Reproductive Health Strategy. • MOH/NASCOP/DRH (2009). National RH/FP/HIV Integration Strategy.
Training Manuals • Adolescent Sexual Reproductive Health. A Trainers Manual for Service Providers. • MOH/USAID (2003). Kenya National Post Abortion Care Curriculum. • MOH- NASCOP/ DRH (2009). National PMCT Training Curriculum.• MOH-DRH/DOMC and JHPIEGO (2002). Focused Ante Natal Care and Malaria in Pregnancy: Orientation Package for the Community.• MOH-DRH/DOMC and JHPIEGO (2004). Focused Ante Natal Care and
August 2010
National Road Map29
Malaria in Pregnancy: Orientation Package for Health Providers. • MOH/DRH: National Reproductive Health Training Plan 2007-2012.
Reports • Strengthening STD/HIV Control project in Kenya: Community Mobilization Module 1 Facts on STI/HIV/AIDS. • MOH/JICA/Population Council (2004). Reproductive health services in Kitui, Kisii, Nyamira and Kericho districts in Kenya: A baseline with special emphasis on safe motherhood. • MOH/WHO (2003). Global Youth Tobacco Survey - Kenya.
August 2010
National Road Map30
Annex IV: Costing of the MNH Road Map
The costing of the MHN Road Map is based on evidence based planning, costing and budgeting. It is aligned to overall guiding principles of the MNH Road Map namely: evidence based; health systems approach and; phased planning and implementation and to the narrative structure of the MNH Road Map. The alignment is achieved using an updated Marginal Budgeting for the Bottlenecks (MBB) version 5.0 toolkit for Kenya. The MBB tool was recently last updated based on the 2008/9 Kenya Demographic and Health Survey, 2009/10 Ministerial Public Expenditure Review (MPER) and 2010/11 budget.
The MBB application has inputs for health system, epidemiology, evidence based interventions and their coverage, economics, finance and budget and, fiscal space. The MBB application for Kenya health system design starts at level 1-community through to level 6 with specific inputs for existing infrastructure and human resources. The epidemiology inputs include current population projections and disease burden. The tool is modeled on evidence based interventions for each of the health system levels, their baseline coverage and Kenya Essential Package for Health (KEPH) priorities. The tool is set with 2009/10 as the baseline for a phased three year planning period hence aligning to current Medium Term Expenditure Framework (MTEF). The economic inputs include various unit costs for the interventions while the finance and budget inputs include probable sources of funding aligned to National Health Strategic Plan II programmes, sub-programmes and MTEF programmes for the health sector. In puts into fiscal space include details on the country’s macro-economic parameters such as GDP, inflation and government revenue expenditure in health.
As shown in Table 1 total additional cost is for MNH Road Map is Ksh. 2 billion in 2009/10 rising to Ksh. 3 billion in 2010/11. The total additional cost reaches the highest level of Ksh.4.1 billion in the 2011/12 financial year. Thereafter, the costs start reducing hence sending the message that investment in MNH starts to pay off with reduced costs after a period of about 3 years.
Evidence based planning is one of the underlying principals of MNH Road Map implementation. The additional cost of monitoring and evaluation in 2009/10 is Ksh.64.5 million, Ksh.127.5 million in 2010/11 and Ksh.192.8 million in 2011/12. The evidence will be collected through a functional monitoring and evaluation system, operations research and used to inform the planning process. The additional cost of operations research in 2009/10 is Ksh.79.5 million, Ksh.150.8 million in 2010/11 and Ksh.222.8 million in 2011/12. On the other hand, the additional cost of evidence based planning in 2009/10 is Ksh.16.5 million, Ksh.33.0 million in 2010/11 and Ksh.49.5 million in 2011/12.
The highest spending levels are in access to and utilization of quality MNH care and
August 2010
National Road Map31
community approaches. The additional cost of access to and utilization of quality MNH in 2009/10 is Ksh.1billion, Ksh.1.2 billion in 2010/11 and Ksh. 1.3 billion in 2011/12. The additional cost for community based approaches increased to a high of about Ksh.1.5 billion in 2011/12 much more higher than the additional cost for access to and utilization of quality MNH care. The community level therefore attracts one of the highest additional indicative costs. This reflects the evidence and potential of community level interventions to substantially influence impact on maternal and newborn status. The high additional indicative cost requirements also reflect low levels of funding for community interventions in the past.
Access to good quality family planning option attracts additional cost of 237.7 million in 2009/10, Ksh.429 million in 2010/11 and Ksh.623 million in 2011/12. MNH related referral costs stand at Ksh.164 million for each of the three financial years. Advocacy and fostering partnerships are key in the implementation of MNH Road Map. As shown in the table 1 below, the costs are lowest but investment in these areas is important.
August 2010
National Road Map32
TAB
LE 1
: M
NH
Roa
d M
ap A
dditi
onal
Cos
ts K
SH (
,000
,000
)
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
2014
/15
2015
/16
2016
/17
2017
/18
2018
/19
2019
/20
2020
/21
2021
/22
1. M
onito
ring
and
Eval
uatio
n
Syst
em fo
r M
NH
64.5
012
7.50
192.
7520
1.75
210.
7521
9.75
228.
7523
7.75
243.
0024
9.75
255.
7526
1.75
267.
00
Com
mun
ity a
nd
outr
each
MN
H M
&E
tool
s
7.50
13.5
021
.00
21.0
020
.25
21.0
021
.00
21.0
021
.00
22.5
022
.50
23.2
523
.25
Fa
cilit
y M
NH
M&
E to
ols
0.75
2.25
3.00
3.75
4.50
4.50
4.50
4.50
4.50
5.25
6.00
6.00
6.00
Su
ppor
t su
perv
isio
n56
.25
111.
7516
8.75
177.
0018
6.00
194.
2520
3.25
212.
2521
7.50
222.
0022
7.25
232.
5023
7.75
2. O
pera
tions
rese
arch
79.5
015
0.75
222.
7520
1.00
186.
0017
0.25
154.
5013
9.50
139.
5013
9.50
139.
5013
9.50
139.
50
3. R
ight
s ba
sed
and
gend
er
mai
nstr
eam
ed
plan
ning
and
man
agem
ent
for
MN
H a
t al
l
leve
ls
16.5
033
.00
49.5
045
.75
42.7
539
.00
35.2
531
.50
31.5
031
.50
31.5
031
.50
31.5
0
4. A
cces
s to
and
utili
zatio
n of
qual
ity M
N c
are
1023
.75
1181
.25
1341
.75
1122
.75
1101
.00
1077
.00
1053
.75
1032
.75
744.
7574
2.50
739.
5073
8.00
738.
00
M
NH
tra
inin
g66
.75
133.
5020
0.25
186.
0017
1.00
156.
7514
2.50
128.
2512
8.25
128.
2512
8.25
128.
2512
8.25
Ad
oles
cent
and
you
th
frie
ndly
ser
vice
s57
.00
112.
5016
9.50
156.
7514
5.50
133.
5012
0.75
108.
7510
8.75
108.
7510
8.75
108.
7510
8.75
D
rugs
, bas
ic s
uppl
ies
and
kits
for
MN
H58
.50
93.7
513
0.50
128.
2513
2.75
135.
0013
8.75
144.
0013
2.75
130.
5012
7.50
126.
0012
6.00
Eq
uipm
ent
for
MN
H84
1.50
841.
5084
1.50
651.
7565
1.75
651.
7565
1.75
651.
7537
5.00
375.
0037
5.00
375.
0037
5.00
5. A
cces
s to
good
qua
lity
FP
optio
ns
237.
7542
9.00
623.
2548
8.25
395.
2530
2.25
209.
2511
7.00
117.
7511
8.50
119.
2511
9.25
121.
50
Fam
ily p
lann
ing
logi
stic
s, s
tora
ge a
nd
tran
spor
tatio
n
50.2
510
0.50
150.
0013
9.50
129.
0011
7.75
107.
2596
.75
96.7
596
.75
96.7
596
.75
96.7
5
Cont
race
ptiv
e su
pplie
s,
buffe
r st
ock
incl
udin
g
perm
anen
t m
etho
ds
187.
5032
8.50
473.
2534
8.75
266.
2518
4.50
102.
0020
.25
21.0
021
.75
22.5
022
.50
24.7
5
6. M
NH
Ref
erra
l-
vehi
cles
and
com
mun
icat
ion
equi
pmen
t
164.
2516
4.25
164.
2542
.00
42.0
042
.00
42.0
042
.00
33.7
533
.75
33.7
533
.75
33.7
5
7. A
dvoc
acy
for
incr
ease
d
com
mitm
ent
and
reso
urce
s fo
r
MN
H a
nd F
P
0.75
2.25
3.75
3.75
3.00
3.00
2.25
2.25
2.25
2.25
2.25
2.25
3.00
8. F
oste
ring
MN
H
Part
ners
hips
3.75
7.50
11.2
510
.50
9.75
9.00
9.00
7.50
7.50
7.50
8.25
8.25
8.25
9. C
omm
unity
base
d M
NH
appr
oach
es
498.
7599
9.75
1500
.00
1403
.25
1305
.75
1207
.50
1110
.75
1014
.00
1037
.25
1061
.25
1084
.50
1107
.75
1130
.25
Com
mun
ity s
ocia
l
mob
iliza
tion
and
dem
and
crea
tion
for
MN
H
18.0
038
.25
57.7
554
.00
50.2
546
.50
43.5
040
.50
40.5
040
.50
40.5
040
.50
39.7
5
In-s
ervi
ce t
rain
ing
and
gove
rnan
ce fo
r M
NH
at c
omm
unity
leve
l
229.
5045
9.75
689.
2570
3.50
717.
0073
0.50
744.
0075
7.50
775.
5079
4.25
812.
2583
0.25
848.
25
CH
Ws
perf
orm
ance
ince
ntiv
es25
1.25
501.
7575
3.00
645.
7553
8.50
430.
5032
3.25
216.
0022
1.25
226.
5023
1.75
237.
0024
2.25
TOTA
L ad
ditio
nal
cost
2089
.50
3095
.25
4109
.25
3519
.00
3296
.25
3069
.75
2845
.50
2624
.25
2357
.25
2386
.50
2414
.25
2442
.00
2472
.75
